5101:3-10-09 Apnea monitors.

(A) Definitions.

(1) "Apnea monitors" are defined as cardiorespiratory monitoring devices capable of providing continuous or periodic two channel monitoring of heart rate and respiratory rate and must meet current food and drug administration guidelines for products in this class. Apnea monitors must have alarming mechanisms to alert caregivers of cardiorespiratory distress or other events that require immediate intervention and must be capable of recording and storing events (sometimes known as memory monitoring) and of providing event recording downloads or printouts of such data.

(2) "Download" is defined as a printout of the two channel (or greater) event recordings from a memory monitor. Normally a download contains waveform printouts, event logs, and compliance and utilization information.

(3) "Sudden infant death syndrome (SIDS)" is defined as the sudden death of any infant or young child under one year of age that remains unexplained after the performance of a complete postmortem investigation, including an autopsy, an examination of the scene of death, and a review of the case history.

(4) "Apparent life threatening event (ALTE)" is defined as an episode that is frightening to the observer and that is characterized by some combination of apnea (central or obstructive), color change (usually cyanotic or pallid but occasionally erythematous), marked changes in muscle tone (usually limpness), choking or gagging. In some cases, the observer fears the infant has died. Terminology such as aborted crib death or near miss SIDS should be abandoned because it implies a possible misleading close association between an ALTE and SIDS.

(B) Apnea monitors are reimbursed on a rent-to-purchase basis in accordance with rule 5101:3-10-05 of the Administrative Code.The medicaid fee includes payment for professional time, event recording(download), and all maintenance and supplies.

(C) The following criteria must be met for coverage of an apnea monitor:

(1) The provider must maintain on file a certificate of medical necessity (CMN) signed by the attending physician documenting at least one or more of the following:

(a) One or more apparent life-threatening events (ALTES) requiring mouth-to-mouth resuscitation or vigorous stimulation;

(b) Symptomatic preterm infant (active medical management of apnea of prematurity);

(c) Sibling of one or more sudden infant death syndrome (SIDS) victims;

(d) Infant requires home oxygen therapy or invasive or non-invasive ventilatory support (technology dependent);

(e) Tracheotomized infant (technology dependent);

(f) Infant with abnormal pneumogram at discharge;

(g) Multiple birth SIDS survivor(s);

(h) Infants with severe gastroesophageal reflux with associated apneas;

(i) Infants with severe upper airway abnormalities (e.g., achondroplasia, Pierre-Robin syndrome, etc.); or

(j) Infants with other disorders, specified on the CMN, that demonstrate a need for close cardiorespiratory monitoring to facilitate a more timely discharge to home.

(2) Requirements for use of home monitoring include but are not limited to the following:

(a) Infant cardiopulmonary resuscitation (CPR) training of caregivers by certified trainers;

(b) Education regarding mechanical aspects of monitors;

(c) In-hospital experience;

(d) Twenty-four hour availability of monitor service staff; and

(e) Attestation by the attending physician that the caregivers are capable of being trained to use the monitor properly.

(3) The following diagnoses or conditions alone are not indications for monitoring:

(a) Seizure disorders (without life threatening events);

(b) Hydrocephalus, uncomplicated;

(c) Mental retardation;

(d) Irreversible terminal conditions;

(e) Congenital heart defects, with or without associated arrhythmias;

(f) Distant family history of apnea or SIDS (other than an immediate sibling);

(g) History of apnea monitor use with other siblings;

(h) History of apnea with other sibling(s);

(i) Parental anxiety or family request for a monitor;and

(j) Monitoring of blood oxygen saturation.

(D) Length of need. Coverage of apnea monitors is generally limited to four months. Apnea monitors should be discontinued as soon as there is no medical indication to support the need for continued home monitoring. If the attending physician recommends continued monitoring beyond the initial rental, evidence to support the medical need must be submitted with the request for subsequent rental or purchase authorization in accordance with paragraphs (D)(1) to (D)(3) of this rule.

(1) Nontechnology dependent infants. Requests for authorization should include:

(a) Evidence that there has been clinically significant apnea or bradycardia within two months before the date of the prior authorization request. Supportive evidence may include a copy of a recent download noting apneas or bradycardias; documentation of a recent pneumogram noting apneas or bradycardias; documentation of a recent emergency room visit or hospital admission for an ALTE;

(b) Download report or download summary information with download report available on request by the department; and

(c) Certificate of medical necessity signed by the attending physician stating the need for continued home monitoring.

(2) Technology dependent child. Requests for authorization should include:

(a) Evidence that the patient is still in need of the high technology products/services. Supportive evidence may include copies of recent clinician follow-up reports noting equipment and services still in use, copies of home nursing agency visits reports noting equipment and services still in use, etc.;

(b) Download report or download summary information with download report available on request by the department; and

(c) Certificate of medical necessity signed by the attending physician stating the need for continued home monitoring.

(3) SIDS sibling. Requests for authorization should include:

(a) Same criteria as noted in paragraph (D)(1)(a) of this rule; or

(b) Patient is not beyond age of the death of the sibling who died of SIDS;

(c) Download report or download summary information with download report available on request by the department; and

(d) Certificate of medical necessity signed by the attending physician documenting the need for continued home monitoring.

(E) Downloads. Recording monitor downloads are covered for recipients receiving home apnea monitor services as part of any payment for service rendered by the department. Downloads are normally used to determine the presence of continued symptoms (apnea/bradycardia) and document such information. They may also be used to document compliance with home monitoring requirements. Download reports provide appropriate, objective medical information that may aid the physician in deciding to discontinue home monitoring or document the need for continued home monitoring.

(F) Pneumograms. For dates of service beginning on or after April 1, 2006, consumers requiring a pneumogram must seek the care of a qualified licensed prescriber in order to have the pneumogram reimbursed by the department. The order for a pneumogram must be based on the presence of appropriate symptoms or conditions as defined by accepted medical standards. Pneumograms used as screening tests without the presence of appropriate symptoms for conditions are not reimbursable by the department.

Effective: 10/15/2006
R.C. 119.032 review dates: 06/15/2006 and 10/01/2011
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.021
Prior Effective Dates: 3/1/84, 5/1/90, 7/1/97, 10/2/97, 12/5/02